You said, we did

Mental Health Services

You said: I was not told that my therapist would not be attending an appointment.
We did: The clinical strategic lead has reviewed the way the team inform patients of a staff absence to ensure they are made aware as soon as possible. (Community AMH)

You said: I was referred to a team out of area because I used to work in the team I should have been seen by.
We did: The service has changed their SOP to ensure that conversations are held with any staff members who may become patients, to ensure their preferences are fully considered. (Childrens, Young People and Families)

You said: My daughter was able to access a lighter on the ward because she had access to someone else's property.
We did: Lockers have been installed on the ward to better control access to patient property and risk items. (Inpatient AMH)

You said: I was left without support while my care co-ordinator was off work.
We did: The team now review the caseloads of staff members who are off work for extended periods to ensure patients are not left without support. (Community AMH)

Forensic Services

You said: Doors banging on the ward kept me awake throughout the night.
We did: The ward manager reminded night staff about keeping the doors on the ward closed to reduce noise disturbance. (High Secure)

You said: I missed an MRI appointment as staff claimed they didn't know the time of the appointment.
We did: The ward manager has reminded staff about preparation for off-site appointments and the need to include these in daily handovers. (High Secure)

You said: My nephew had no footwear when placed in strong safety clothing.
We did: The Restrictive Practice team are looking at commissioning suitable safety footwear. (High Secure)

You said: My wrist was harmed and swollen because the cuffs were not locked in place properly.
We did: Training is being considered for staff to ensure they know how to correctly cuff patients. (High Secure)

Community Health Services

You said: I was misnamed and misgendered by a staff member.
We did: The patient record operating procedures and staff training have been updated to make clear where staff should seek patient details. (Specialist Services)

You said: My child's prescription was changed based on a telephone assessment.
We did: The service will be offering more options for appointments so that families can follow their preferences, including having a face-to-face assessment. (Children, Families and Specialist Services)

You said: I received inaccurate and conflicting information about my family member's discharge.
We did: Discharge co-ordinators are now allocated to specific wards so they can build relationships and provide clear communication to patients, family and carers. (Urgent Care)

You said: I received a standardised letter following the care team's sessions with my child. This was not helpful to our family.
We did: The process has been improved to make the letters more personalised and where helpful families will be offered an additional session on how to support the patient. (Children, Families and Specialist Services)

Mental Health Services

You said: “While on the ward I received inconsistent care depending on who was working.”
We did: Inpatient services are changing to a consistent model of care delivery. All patients will be allocated a worker for each shift with responsibility for the patient’s care. (AMH)

You said: “I was discharged because I was not supported to fully engage in the sessions.”
We did: The service operational manual now has an updated process on reviewing engagement as part of the engagement agreement. (AMH)

You said: “My child’s clinician did not provide enough information for the EHC assessment.”
We did: The complaint was anonymously discussed in a team meeting to reaffirm the expectations and standards when contributing to an EHC assessment. (CAMHS)

You said: “There were a limited number of activities available on the ward.”
We did: The environment co-ordinators are developing an evolving list of activity options. (AMH)

Forensic Services

You said: “My laundry was taken by another patient.”
We did: The ward manager has implemented an updated procedure for managing patient access to laundry. (High Secure)

You said: “I was unable to access fresh air as there were not enough staff on the ward.”
We did: The issue of fresh air will be discussed in community meetings so that the issue can be monitored. (High Secure)

You said: “There was a delay of two hours between me requesting medication and being provided with it as the night shift left the issue for the day shift to deal with.”
We did: The ward manager reminded staff of the importance of ensuring requests for medication are handed over to the next shift to prevent delays caused by shift changes. (High Secure)

You said: “My planned family visit was cancelled due to staffing shortages.”
We did: The availability of visits has been reduced to ensure that any visits that are booked will not be cancelled due to staffing levels. (High Secure)

Community Health Services

You said: “There were delays in my child’s care due to the complex systems between multiple services.”
We did: The Family Hubs initiative is being trialled. This is a collaboration of agencies working to improve communication and more efficiently refer patients to the most appropriate services. (Children, Families and Specialist Services)

You said: “My father was sent to the acute hospital without an escort.”
We did: The service now has a process in place that ensures all patients either have a confirmed plan with a family member or else they will be provided with a nurse escort. (Urgent Care)

You said: “I was not updated when my mother was transferred to hospital during the night.”
We did: At admission the team will take family communication preferences, including when they would like to receive updates and who would be best to contact. (Urgent Care)

You said: “I was not updated on my mother’s care while my sister, the listed contact, was away.”
We did: Staff have been asked to contact the patient’s GP for family contact information when there are no suitable contact details on the patient record. (Urgent Care)

Mental Health Services

You said: “My assessment for ASD appeared inadequate as they just asked my family questions.”
We did: A guide has been produced for service users so they know what to expect from the assessment process. (SSD)

You said: “My child was not seen by a mental health worker when we went to A&E.”
We did: There are now mental health liaison staff available 24/7 for young people in A&E. (CAMHS)

You said: “A patient shared positive feedback about some staff members.”
We did: The staff members identified as showing good practice have been buddied with new starters so that they can model compassionate care. (AMH)

You said: “Staff did not know how to work with my child due to their ASD needs.”
We did: The service now has specialist practitioners to work with young people with ASD. They will also train and support the wider team. (CAMHS)

Forensic Services

You said: “I was not restrained in a safe or appropriate way.”
We did: Patient debriefs will be offered after restraint incidents. (High Secure)

You said: “The ward was unsafe because the ward team did not meet the minimum number of staff required in the day room.”
We did: The ward has created an integrated planner so staff are always aware of the patient and staff numbers in the dayroom. (High Secure)

You said: “I was worried about my privacy when male staff tried to complete my observations while I was in the shower.”
We did: Patients have been provided with an ‘I’m in the shower’ poster that they can put on their door. This will alert staff and allow them to seek a female staff member for the observations. (High Secure)

You said: “When I was in seclusion staff did not provide me with any toilet roll when I asked.”
We did: The issue was highlighted with staff, who were reminded of patients’ rights. (Low Secure)

Community Health Services

You said: “I struggled to contact the team I needed as I had to go through an admin hub.”
We did: The service has revised their leaflets to include details on how to contact the service directly. (Proactive and Planned Care)

You said: “My visits kept being deferred as there were not enough staff.”
We did: The team now have a Shift Lead to co-ordinate the shift and liaise with patients when visits need to be deferred. (Proactive and Planned Care)

You said: “My father’s referral was not treated as a priority. He had several falls while waiting for support.”
We did: New triage guidelines have been published. Staff will be trained on these guidelines to ensure they triage referrals effectively. (Urgent Care)

You said: “There were several issues with the care and communication provided by my uncle’s inpatient team.”
We did: Initial assessments are undertaken within 24-48 hours so a clear plan can be made with patients and families. Written information is shared with patients and families on the reason for admission and process that will be followed. (Urgent Care)

Mental Health Services

You said: “There were not enough good activities to do while on the ward.”
We did: The ward now works with patients to include their ideas on the activity timetable. (AMH)

You said: “I was not made aware that my son had been made an informal patient. My family were not included in this decision.”
We did: Training has been arranged for ward staff on the importance of carer input and support. (AMH)

You said: “I was not informed that support for my child’s ADHD needed to be looked at by the GP.”
We did: The team have developed an information booklet on how to access support for children with ADHD. This will be shared with families when needed. (CAMHS)

You said: “The self-referral for my daughter was not reviewed for six days.”
We did: The service now have a daily allocated clinician who screens all referrals on the day they are received. (CAMHS)

Forensic Services

You said: “I was not given meals that suited my vegan diet.”
We did: A dietician gave the catering team training on vegan meals. (Medium Secure)

You said: “Staff were leaving my light on after completing nighttime observations.”
We did: The ward has placed signs outside every room as a reminder for staff to turn the light off after completing the observation. (High Secure)

You said: “I was assaulted by another patient as the dining room was unsupervised while staff were elsewhere.”
We did: The team will develop a Standard Operating Procedure to compartmentalise the ward when short staffed. (High Secure)

You said: “There was a lack of activities and structure on the ward.”
We did: Staff and patients are working together to develop an achievable activity timetable. (High Secure)

Community Health Services

You said: “The district nurse was rude to me when she came to change my dressings.”
We did: Staff have undertaken the ‘Fifteen Steps Challenge’ to re-focus on what a ‘good visit’ looks like to a patient. (Proactive and Planned Care)

You said: “My vulnerable mother was not visited because no staff member was allocated to her appointment.”
We did: A new system has been introduced which automatically allocates a worker to each visit. (Urgent Care)

You said: “My mother fractured her leg after falling on the ward.”
We did: The ward has introduced a new process for ensuring risk assessments are completed weekly. (Urgent Care)

You said: “There was a delay in receiving continence pads because the care home did not know how to liaise with the continence service.”
We did: There is a new system in place for how the continence service works with care homes. A conference was held to increase care homes knowledge of the process. (Proactive and Planned Care)

Mental Health Services

You said: “I was not aware if my self-referral had been accepted or whether I had been added to a wait list for treatment.” 
We did: There is now an automated response to confirm a self-referral has been accepted and is being considered. Each team also has a welcome pack which includes a referral acceptance letter that explains the next steps.  (CAMHS)

You said: “I had several concerns with the lack of communication and support from the LMHT Duty team.”
We did: The Duty system across community teams is being reviewed by senior management to improve its effectiveness. (AMH)

You said: “The service declined my referral despite not having a set referral criteria.”
We did: The service have developed a set of referral criteria which have been publicised on their website.  (CAMHS)

You said: “My complex needs were not supported as I moved between mental health services.”
We did: There is now a transitions team in place to support patients with neurodiversity as they transition between services. (AMH)

Forensic Services

You said: “I was not given a seclusion care plan or exit plan when in seclusion.”
We did: There is an ongoing Quality Improvement Project across the hospital to improve how seclusions are managed by staff. (High Secure)

You said: “Staff were not aware of the need to contact Advocacy to support me in seclusion.”
We did: Ward teams have been reminded of the need to contact Advocacy when a patient is placed in seclusion. Advocacy leaflets have also been included in seclusion packs. (High Secure)

You said: “I was restrained despite me not resisting.”
We did: The Positive and Safe Violence Reduction team have a new training package on de-escalating situations using verbal communication. (Medium Secure)

You said: “I was not made aware why my psychology appointments were cancelled.”
We did: The team have developed a new system for letting patients know about staff absences when these affect appointments. (High Secure)

Community Health Services

You said: “The district nurses were not able to manage my mother’s pressure sore, so it grew worse.”
We did: Staff have received training on pressure sore identification, management, and treatment. Policy has also been reviewed to ensure it is in line with NICE guidance. (Proactive and Planned Care)

You said: “There was a delay to my appointment because my referral was not correctly triaged.”
We did: A new streamlined triage system has been introduced along with a new Standard Operating Procedure. (Proactive and Planned Care)

You said: “My family had no idea what to expect from our loved ones’ end of life care.” 
We did: The service now has a leaflet with information on end of life care which will be shared with family members. (Proactive and Planned Care)

You said: “The team did not consistently reply to the concerns that I raised with staff.” 
We did: The care unit have developed a local process to ensure all staff are aware of what to do when concerns are raised with them. (Children, Families and Specialist Services)

Mental Health Services

You said: “My husband did not receive timely support following a mental health assessment at A&E.” 
We did: The service have developed a new Standard Operating Procedure, which includes being able to offer patients additional support to prevent frequent attendance at A&E.  (MHSOP)

You said: “My community team were going to discharge me because I missed one appointment.”
We did: The service manager gave a presentation to the team on the relevant policy to follow when raising missed appointments with a patient.  (AMH)

You said: “A specialist team declined my daughter’s referral as she did not meet their criteria. But they have no clear referral criteria.”
We did: The service have developed and agreed a set of referral criteria. These have also been uploaded to their website. (CAMHS)

You said: “I missed appointments because my team did not follow my communication preferences when informing me of appointment times.”
We did: An alert has been placed on the patient’s record to highlight their communication needs. (AMH)

Forensic Services

You said: “Low staffing levels are affecting care and access to activities on the ward.”
We did: There is an ongoing Rampton Recovery Plan to improve recruitment and retention of staff at Rampton hospital. (High Secure)

You said: “I was inappropriately restrained when I was not resisting.”
We did: The Positive and Safe Violence Reduction team have a new and robust training package around de-escalating through verbal communication. (Medium Secure)

You said: “I was not allowed to wear a colourful camouflage print clothing, despite other patients having similar items.”
We did: The decision was reviewed, and the patient was allowed this item of clothing as it would not pose a risk. (High Secure)

You said: “I was not told why my psychology appointments were repeatedly cancelled.”
We did: The psychology team have put a new system in place for letting patients know about staff absences. (High Secure)

Community Health Services

You said: “I kept being sent inconvenient appointment times, instead of the service calling me to agree a suitable appointment date.”
We did: The service have a new ‘live’ booking system that allows them to book appointments while speaking with service users. (Children, Families and Specialist Services)

You said: “I was not comfortable with a trainee staff member being present in my appointment.” 
We did: The team have been reminded that staff leading an appointment should ensure service users are comfortable with a trainee’s presence. (Children, Families and Specialist Services)

You said: “The service did not communicate with my mother’s previous care team in a different county.”
We did: The team have gained the contact details for neighbouring services to improve their liaison with teams outside the trust. (Proactive and Planned Care)

You said: “It was difficult to contact the team as they rarely answered the phone.” 
We did: The service upgraded the telephone system and increased the phone opening hours in line with standard office hours. (Children, Families and Specialist Services)

Mental Health Services

You said: “The staff at the hospital I was transferred to said they did not have access to my medical history.” 
We did: The patient’s medical history had been transferred between hospitals; however, the service recognised it would be useful to have a checklist of information to share when a patient is transferred.  (AMH)

You said: “My daughter was discharged without her parents being consulted.”
We did: The ward round template has been updated to ensure families or carers are invited to ward rounds where they can contribute to the discussion of patient care. (AMH)

You said: “I did not feel the assessing clinicians had considered my son’s needs, including his Autistic traits.”
We did: The team have undertaken SEN (Special Educational Needs) training and they have been supported by a neurodevelopmental specialist on cases involving ASD and mental health. (SSD)

You said: “I emailed the service with an enquiry but received no contact about whether my request had been handled or not.”
We did: The team will acknowledge receipt of enquiries so that people are aware their matter is being progressed.  (SSD)

Forensic Services

You said: “There was a lack of activities available on the ward.”
We did: The ward manager agreed to provide a daily planned activity timetable with a coordinator to oversee it. There will also be community projects, such as Christmas decorations, for patients to be involved in. (High Secure)

You said: “I raised concerns directly with the service, but these were not addressed.”
We did: The local procedure for resolving concerns has been reviewed to ensure concerns raised by patients are addressed. (Offender Health)

You said: “There was a delay in my long term segregation plan being approved.”
We did: The team will ensure that all members of the MDT are contacted promptly to reduce delays in the approval process. (High Secure)

You said: “My son was given a triple dose of his medication which made him unwell.”
We did: The investigation noted that prescription checks had failed when issuing medication. This was addressed by the Matron in supervision meetings. (Offender Healthcare)

Mental Health Services

You said: “Staff were not completing observations at night as they were asleep.”
We did: While there was no evidence of this occurring a new process has been introduced where random checks will ensure observations are being completed appropriately.  (AMH)

You said: “There was a missed opportunity for two CAMHS teams to discuss my daughter’s complex formulation when her care was transferred between teams.”
We did: There is a newly established role of CAMHS Complex Case Manager to support the transition of complex young people between teams and with external agencies. (CAMHS)

You said: “There were delays between first and second appointments, and with surgical recommendations, due to pressure on clinicians in the service.”
We did: The service have recruited more clinicians and have changed job plans so that patients see multiple clinicians who are trained to support them at different points in the treatment pathway. (SSD)

You said: “My discharge summary was sent to a previous GP that was still on my records.”
We did: GP information will be checked with patients on admission. This has been added to the admission checklist to ensure that it is completed.  (SSD)

Forensic Services

You said: “My welfare checks were not completed while I was in segregation.”
We did: The team have revised their duties to ensure all welfare checks are completed for patients in segregation. This includes checking the appointment ledgers at the end of each day to ensure all appointments were completed. (Offender Health)

You said: “I was not able to eat or drink due to pain in my jaw, but this was not addressed by staff.”
We did: While Healthcare had provided medication in the future they will also liaise with Kitchens about providing a modified diet, such as softer food, to meet patient needs. (Offender Health)

You said: “I had to raise safety concerns as staff were conducting corridor checks alone which could have ended badly.”
We did: Observations will be completed in pairs whenever possible. When not possible staff will request their colleagues monitor them on CCTV during corridor checks, to ensure patient and staff safety. (High Secure)

You said: “I was not allowed a spork due to my risk and there were no spoons available meaning I would have had to eat with my hands.”
We did: There is now an adequate stock of paper spoons for safe use when eating. (High Secure)

Mental Health Services

You said: “My child was inappropriately referred to two specialist services which delayed their access to treatment.”
We did: The LMHT was made aware of the referral criteria for the specialist services so that they are aware of which patients will be accepted by these services.  (AMH)

You said : “The support for my daughter was confused as there were several agencies involved in her care.”
We did: The service manager is liaising with the ICB about having a complex case manager who will co-ordinate the actions of different agencies when there are multiple agencies involved in a patient’s care. (CAMHS)

You said: “An admin error delayed me receiving a letter declining my referral.”
We did: The admin team have streamlined the letter process, including the use of letter templates, to better manage the volume of letters that need to be produced and sent out. (SSD)

You said : “My post-assessment letter was not an accurate reflection of what was documented during the assessment.”
We did: The practice development lead and admin lead have developed a new process for producing letters that are sent to GPs following assessments.  (MHSOP)

Forensic Services

You said: “I was erroneously referred to the wrong hospital department due to an admin error.”
We did: Paper referrals have stopped being used and electronic referrals are now in place. Staff have received training on the process to ensure errors are avoided. (Offender Health)

You said: “There were no prescribers available in mornings to sign off prescriptions.”
We did: Healthcare has recruited two new part-time GPs and a substance misuse team prescriber which should improve availability of prescribers. (Offender Health)

You said: “I was not reviewed by Healthcare when I returned to the site from an external hospital.”
We did: Healthcare will have a ledger to monitor patients who are going to hospital and will only remove them from the ledger once the review has been completed. (Offender Health)

You said: “I was allowed to assault a peer because my care plan was not properly followed.”
We did: Where possible regular ward staff will be allocated to patients who present with the most challenging behaviours. (High Secure)

Community Health Services

You said : “My child was upset by a visit to the site and refused to return for future care.”
We did: The service arranged a friendly visit to the site so that the patient could experience it without upset and recover from the previous encounter. (CF&SSD)

You said : “There was a significant delay in my child’s appointment due to a lack of available staff.”
We did: The service is recruiting additional speech and language therapists to help with an increased demand. (CF&SSD)

You said: “There was no documentation of my referral that had been rejected by the service.”
We did: The clinical leads have now been given responsibility for documenting outcomes of referrals. (Planned and Proactive Care)

You said: “The ward team did not monitor the changing needs of my mother.”
We did: Lings Bar hospital is undertaking a rapid improvement program with various aspects of care being reviewed and additional training being provided. (Urgent Care)

Mental Health Services

You said: “My son with Autism was not being managed appropriately on the ward.”
We did: A lead psychologist is reviewing the ward environment and a lead practitioner for neurodiversity will be developing a training package on supporting adults with Autism. (AMH)

You said: “When I called the team, I could hear people in the background joking and laughing while my child was in distress.”
We did: New headphones are being used which reduces the amount of background noise that callers can hear. Clinicians will also be moved to a different office space so there is more privacy when handling calls. (SSD)

You said: “I found the way staff spoke to a young person in crisis to be patronising and unsupportive.”
We did: The team are undergoing training on how to manage crisis calls with young people and they are seeking feedback from young people and carers in order to improve the service. (SSD)

You said: “The service did not make reasonable adjustments for my Autism when arranging appointments.”
We did: The service has introduced changes to support patients with Autism, including ensuring appointments are face to face and having a support worker present if needed. (AMH)

Forensic Services

You said: “My needs were not being met during night-time confinement.”
We did: The team are installing a co-wall in the patient’s bedroom to support her communication needs and ease her levels of distress. (High Secure)

You said: “The hot water comes out of the tap at boiling temperature.”
We did: The Estates team reduced the temperature of the tap water. (High Secure)

You said: “Information from my CPA was given to another patient for signing.”
We did: All reports are now sent separately after being checked by the ward manager and PA. (High Secure)

You said: “I was discouraged from talking to my peer in a dialect that staff could not understand.”
We did: The relevant Equality Diversity and Inclusion policy is under review as the staff members actions were found to be inappropriate. (High Secure)

Mental Health Services

You said: “My family were not greeted in a friendly or helpful manner by staff on the ward.”
We did: Training has been arranged for staff about body language and verbal communication. More fluid working with relatives and carers is also being promoted. (AMH)

You said : “I did not understand the role of the Crisis team when calling on behalf of my brother so I didn’t realise they would be able to help.”
We did: Staff have been reminded that it is essential to inform carers and service users of the function of the team so that they can make informed decisions. (AMH)

You said: “I have struggled to get through to the service on the telephone when I have queries about my care.”
We did: The service is trialling a new phone triage system to ensure that service users with complex queries can be responded to while people with simple enquiries are directed to the website to free up the line. (SSD)

You said : “I did not have a clear view or understanding of the therapy model offered to me.”
We did: The Step 4 information leaflet has been amended so there is clear written information about the assessment process and the nature of the therapeutic interventions. (AMH)

Forensic Services

You said: “The incorrect medication was administered by an agency nurse, but this was not addressed at the time.”
We did: Staff have been made fully aware of the process in place following an error to ensure that Duty of Candour is followed. (Offender Healthcare)

You said: “The pharmacy incorrectly recorded that I had been handed too much medication which meant they would not give me the medication I needed.”
We did: The staff members involved have been spoken to about this issue and are under supervision for medication management compliance. (Offender Healthcare)

You said: “A staff member was bullying me and claimed it was banter.”
We did: The investigation found that the staff member had been targeted by the patient but there was limited documentation to support this. The ward manager raised the case on a relational security day for the teams learning. (High Secure)

You said: “When visiting a patient, the staff member I spoke to had a very cocky attitude.”
We did: The ward manager spoke with all staff about this case and the importance of being aware of their presentation when supervising visits. (High Secure)